Question About Fluid Resuscitation with Burns

chare · Nov 10, 2017

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Pt gets 3100 mL in first 8 hrs
Pt gets 3100 mL in next 16 hrs
You have to adjust the formula to reflect initiation of fluids at the time of injury
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Started at 0400 (1 hr after burn injury), now 0900 â€“ Received for 5 hrs (need it for 6 hrs because adjust formula to reflect initiation of fluids at time of injury, which was 0300, and 0300 to 0900 = 6 hours).
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I think this is where some of the confusion arises. The Parkland formula, which you are using, estimates the fluid resuscitation requirements for burn patients, during the first 24 hour period, starting at the time of the injury. This primarily affects the infusion rate for the first half of the calculated volume.

Let's use the patient you describe in your initial post, who should receive 3100 mL during the first 8 hours. If the infusion is started at 0300, the time of injury, which is unlikely, it would infuse over 8 hours, or 387.5 mL/hour. If the infusion is started at 0400, or 1 hour post injury, it would infuse over 7 hours, or 442.9 mL/hour. If the infusion started at 0500, or 2 hours post injury, it would infuse over 6 hours, or 516.7 mL/hour. You would continue this, depending upon what time the infusion was started.

Two key points that you always need to remember are:

1. What is the volume that you need to infuse?

2. How much time is left in the initial 8 hour period from

the time that the infusion is started

.

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[/b]To calculate mL/hr for the first 8 hrs, you need to divide by 7 (instead of 8) because the fluid resuscitation should begin at the time of injury (0300) but began an hr later at 0400, so the pt missed an hr. You need to account for that missed hr. You do this by dividing by 7 instead of 8 (b/c pt should receive the first half of the total 24 hours of fluid resuscitation (i.e., 3100 mL) in the first 8 hrs. If the fluids were started an hr after the time of injury, that means the fluids were started an hr late, so instead of running for 8 hrs, they will run for 7 hrs â€“ this is b/c if the starting of fluids is delayed, then the same amount of fluid is given over the remaining time â€“ in this case, the start of fluids was delayed 1 hr (burned at 0300, started fluid resuscitation at 0400), so the remaining time is 7 hrs (8 hrs â€“ 1 hr delayed = 7 hrs).
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Again, I think this is where a lot of confusion arises. The time of injury is only important in determining the end time of the initial 8 hour period post injury. Once you have determined these, the time of injury is not important. The infusion rate of the first 3100 mL is based upon how much time remains in the 8 hour period from the start of the infusion.

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Do you subtract the missed hr from total hrs? I know that the pt needs to get the first half in the first 8 hrs after the injury, so if they miss an hr, then you need to adjust for that. If an hr was missed, you run the fluids over 7 hours so that the pt gets the required amount of fluid within 8 hrs from the time of injury. Is this because the pt will get more fluid per hr running it over 7 hrs, which makes up for the missed hr?
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Again, once you have determined the ending time for the initial 8 time period forget the time of injury and base all of your calculation on the time remaining until the end of the first 8 hour time period. The infusion rate for the second half of the calculated volume should not be affected.

Thanks for your response!
Again, I apologize for my post regarding having to adjust the infusion rate, but thought you were asking that in your initial post. Having done so, let me clarify.

If you were to receive this patient in transfer, you need to ensure that the fluids were administered at the correct rate. To do this, you need to know three things:

1. How much fluid should the patient receive during the first 8 hour period?
2. How much fluid has he received?
3. How much time is remaining until the end of the first 8 hour period?

Again, let's consider the patient in your initial post. You receive him in transfer from another facility at 0600, three hours post injury. His calculated fluid replacement requirement for the first 8 hours is 3100 mL. If his fluids were initiated at 0400 at a rate of 442.9 mL, he would have received 885.8 mL. As you have 5 hours remaining, he will receive an additional 2214.5 mL of fluid, for a total of 3100.3 mL, exactly what he should have received.

If on the other hand, the infusion had been started at 0400 at 300 mL/hour, when you receive the patient at 0600 he would have received 600 mL. If you continue the infusion at 300 mL/hour for the remaining 5 hours he will receive an additional 1500 mL, for a total volume of 2100 mL; this leaves a deficit of 1000 mL. To adjust the rate, subtract eh 600 mL that he has already received from the 3100 mL that he should receive during the first 8 hours. Doing so demonstrates that the patient needs to received 2500 mL in the next 5 hours to receive the total calculated volume, of 500 mL/hour.

I know that I'm starting to sound like a broken record with this, but these are the key points that should be remembered.

1. The time of the injury is only important in calculating the time for the initial 8 hour period.
How much fluid should the patient receive during the first 8 hour period?
2. How much time is remaining until the end of the first 8 hour period?

In addition, if you receive the patient in transfer,

1. How much fluid has he received?
At the current infusion rate, how much fluid will the patient receive in the time remaining in the initial 8 hour period?
2. When you combine both volumes, will the patient have received the total calculated volume for the initial 8 hour period?

You might find the Medscape (requires free registration to access) Burn Resuscitation and Early Management article helpful.

KrCmommy522, BSN, RN · Nov 12, 2017

Ohhhhhh!! Now I get it!!! Thank you sooo much for hanging in there with my persistence!!

I was just focusing on the time of injury for my entire calculations. But I get now that you use it to calculate at what time the fluids should be finished by (how much time you have to give the fluids in).

You've made it much clearer for me!

Even with the confusion, I appreciate what you added in. It helped me understand it even better and I learned more! :)

Again, thank you so much for all of your help!! I really really appreciate it!

chare · Nov 12, 2017

You're welcome.